1245459189 NPI number — DR. MARY TROTTY NICKSON PH.D.

Table of content: DR. MARY TROTTY NICKSON PH.D. (NPI 1245459189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245459189 NPI number — DR. MARY TROTTY NICKSON PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICKSON
Provider First Name:
MARY
Provider Middle Name:
TROTTY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TROTTY
Provider Other First Name:
MARY
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1245459189
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
807 RIDGEMONT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALLEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75002-5075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-396-1970
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 ALLENTOWN PKWY
Provider Second Line Business Practice Location Address:
#114
Provider Business Practice Location Address City Name:
ALLEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75002-4200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-747-0059
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/25/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  11170 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 103TC1900X , with the licence number: 25148 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 103TS0200X , with the licence number: 30454 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)